Preventive Pharmacologic Treatments for Episodic Migraine in Adults

Abstract

ELIGIBILITY CRITERIA: English-language randomized controlled trials (RCTs) of preventive drugs compared to placebo or active treatments examining rates of ≥50 % reduction in monthly migraine frequency or improvement in quality of life. STUDY APPRAISAL AND SYNTHESIS METHODS:We assessed risk of bias and strength of evidence and conducted random effects meta-analyses of absolute risk differences and Bayesian network meta-analysis. RESULTS: Of 5,244 retrieved references, 215 publications of RCTs provided mostly low-strength evidence because of the risk of bias and imprecision. RCTs examined 59 drugs from 14 drug classes. All approved drugs, including topiramate (9 RCTs), divalproex (3 RCTs), timolol (3 RCTs), and propranolol (4 RCTs); offlabel beta blockers metoprolol (4 RCTs), atenolol (1 RCT), nadolol (1 RCT), and acebutolol (1 RCT); angiotensin-converting enzyme inhibitors captopril (1 RCT) and lisinopril (1 RCT); and angiotensin II receptor blocker candesartan (1 RCT), outperformed placebo in reducing monthly migraine frequency by ≥50 % in 200-400 patients per 1,000 treated. Adverse effects leading to treatment discontinuation (68 RCTs) were greater with topiramate, off-label antiepileptics, and antidepressants than with placebo. Limited direct evidence as well as frequentist and exploratory network Bayesian meta-analysis showed no statistically significant differences in benefits between approved drugs. Off-label angiotensin-inhibiting drugs and beta-blockers were most effective and tolerable for episodic migraine prevention. LIMITATIONS:We did not quantify reporting bias or contact principal investigators regarding unpublished trials. CONCLUSIONS: Approved drugs prevented episodic migraine frequency by ≥50 % with no statistically significant difference between them. Exploratory network meta-analysis suggested that off-label angiotensin-inhibiting drugs and beta-blockers had favorable benefit-to-harm ratios. Evidence is lacking for longterm effects of drug treatments (i.e., trials of more than 3 months duration), especially for quality of life.KEY WORDS: migraine; evidence based medicine; adverse drug effects.

Meditation for Migraines: A Pilot Randomized Controlled Trial

“…However, only about half of migraineurs have clinically meaningful responses to preventive drug treatments, more than 10% discontinue due to adverse events, 1 and half report dissatisfaction with their current treatment strategies. However, only about half of migraineurs have clinically meaningful responses to preventive drug treatments, more than 10% discontinue due to adverse events, 1 and half report dissatisfaction with their current treatment strategies.…”

Evaluation of a Workplace-Based Migraine Education Program

“…Randomized controlled studies of 59 drugs from 14 drug classes have demonstrated some value of preventive treatment for episodic chronic migraine headache. 26 Such medications may decrease the frequency of migraine up to 50%. Although employees of the company in the current study had access only to a CDHP, most of these migraine drug classes are now generic and available at low cost.…”

Pharmacokinetic and pharmacodynamic interactions between antiepileptics and antidepressants

“…For migraine prophylaxis, meta-analyses support the efficacy of approved drugs including topiramate and valproate [115,116] and off-label TCAs, particularly amitriptyline [115,117]. There is limited evidence for the use of some other antidepressants, including venlafaxine [115], but clomipramine is considered ineffective in migraine prophylaxis [23].…”